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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> �. <br /> SITE.. FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> /' COMPLETE THIS FORM FOR EACHCILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILDY/SITE NAME CARE OF ADDRESS INFORMATION <br /> FACE <br /> ,9 <br /> ADDRESS — _ w NEAREST CROSS STREET ✓Bombioitla ❑ PARMOWIP ❑ STATE-AGENCY <br /> OCOWND A. OO LCMfYA G ❑ PFDERuAGBNGY <br /> CITY NAME STATCZIP GODS. SITE PHONE /IAREA (/ <br /> G A O V <br /> TYPE OF BUSINESS: F] 2 DISTRIBUTOR Ll 4 PROCESSOR ✓Box tl INDIAN EPA u S 1./AV-/I} 77 <br /> #of TANK' <br /> ❑ RESE <br /> 1 GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ElAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> lgeM <br /> aoy y7�-y� <br /> NIGHTSNAME(LAST, IRST)) , PHONE WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sao Al <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box toxtdicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY41 JURISDICTION W AGENCY M FACILITY ID R S of TANKS at SITE " <br /> 6C) ioa3 oU00 <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVEDL <br /> PHONE F WITH AREA CODE <br /> G <br /> PERMIT NUMBER PERMIT APPROVAL DATE XPIRATION DATE <br /> LO ONCODE CENSUS TRACT SUPERVISOR-DISTRICT CODE S P SN❑FILEO No DATE FI / � ^O <br /> �o Y <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE RECEIPT• BY: <br /> LTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION OWN—.- <br /> r�RvU ''`� <br /> �ll <br />